Nevada's approach to dispatching mentally ill patients has come under scrutiny since one of their clients turned up suicidal and confused at a Sacramento homeless services complex.

Over the past five years, Nevada's primary state psychiatric hospital has put hundreds of mentally ill patients on Greyhound buses and sent them to cities and towns across America.

Since July 2008, Rawson-Neal Psychiatric Hospital in Las Vegas has transported more than 1,500 patients to other cities via Greyhound bus, sending at least one person to every state in the continental United States, according to a Sacramento Bee review of bus receipts kept by Nevada's mental health division.

About a third of those patients were dispatched to California, including more than 200 to Los Angeles County, about 70 to San Diego County and 19 to Sacramento.

In recent years, as Nevada has slashed funding for mental health services, the number of mentally ill patients being bused out of southern Nevada has steadily risen, growing 66 percent from calendar years 2009 to 2012. During that same period, the hospital has dispersed those patients to an ever-increasing number of states.

By last year, Rawson-Neal bused out patients at a pace of well over one per day, shipping nearly 400 patients to a total of 176 cities and 45 states across the nation.

Nevada's approach to dispatching mentally ill patients has come under scrutiny since one of their clients turned up suicidal and confused at a Sacramento homeless services complex. James Flavy Coy Brown, who is 48 and suffers from a variety of mood disorders including schizophrenia, was discharged in February from Rawson-Neal to a Greyhound bus for Sacramento, a place he had never visited and where he knew no one.

The hospital sent him on the 15-hour bus ride without making arrangements for his treatment or housing in California; he arrived in Sacramento out of medication and without identification or access to his Social Security payments. He wound up in the UC Davis Medical Center's emergency room, where he lingered for three days until social workers were able to find him temporary housing. Nevada mental health officials have acknowledged making mistakes in Brown's case, but have made no apologies for their policy of busing patients out of state. Las Vegas is an international destination and patients who become ill while in the city have a right to return home if they desire, the state's health officer, Dr. Tracey Green, told Nevada lawmakers during a hearing last month.

She and others insist that the vast majority of patients they are discharging to the Main Street bus station are mentally stable and have family members, treatment programs or both waiting for them at the end of their rides.

That was not true in Brown's case. His papers from Southern Nevada Adult Mental Health Services read: "Discharge to Greyhound bus station by taxi with 3 day supply of medication" and provided a vague suggestion for further treatment: "Follow up with medical doctor in California." Brown said staff at Rawson-Neal advised him to call 911 when he arrived in Sacramento.

Nevada Health and Human Services director Michael Willden told lawmakers last month that while health officials "blew it" in their handling of Brown, an internal investigation found no pattern of misconduct.

But an investigation by the Nevada State Health Division documented several other instances from a small sampling of cases in February in which the state hospital violated written rules for safely discharging mentally ill patients.

Other apparent violations surfaced during the Bee's investigation.

At least two patients from the Nevada system arrived in San Francisco during the past year "without a plan, without a relative," said Jo Robinson, director of that city's Behavioral Health Services department.

"We're fine with taking people if they call and we make arrangements and make sure that everything is OK for the individual," Robinson said. "But a bus ticket with no contact, no clinic receptor, anything, it's really not appropriate."

Robinson said she viewed the practice as "patient dumping," and has reported it to federal authorities. "It's offensive to me that they would show this lack of care for a client," she said.

Nevada mental health officials did not respond to repeated requests for phone interviews for this story, nor would they address a list of emailed questions about the origins of the busing policy and the safety protocols in place.

Southern Nevada Adult Mental Health Services, the agency that oversees Rawson_Neal, maintains detailed written policies for transporting patients "to their home communities," with the stated goal of providing more appropriate care by the most economical means possible.

The policy includes a special section on "Travel Nourishment Protocol," specifying the number of bottles of Ensure nutritional supplement the patient should receive for their bus trip _ essentially six per day.

Staff members are supposed to fill out a "Client Transportation Request" form, which includes questions about whether the patient is willing to go, whether housing or shelter has been verified, and the cost of the trip.

The written policy calls for staff to confirm that a patient has housing or shelter available "and a support system to meet client at destination." They are to provide information about "mental health services available in the home community."

Interviews with health officials in California and numerous other states indicate Nevada's practices are unusual. None of the 10 state mental health agencies contacted by the Bee said that placing a psychiatric patient on a bus without support would be permissible. And none recalled being contacted by Rawson-Neal to make arrangements for a patient coming from Nevada.

In California, where most public mental health treatment is overseen at the county level, agencies contacted by the Bee said they rarely bus patients and that Nevada's practices seem out of step with the standard of care.

Several described the practice as risky, even if patients have someone waiting for them at the end of their journeys.

"Putting someone whose mental illness makes them unable to care for themselves alone on a bus for a long period of time could be absolutely disastrous," said Dorian Kittrell, executive director of the Sacramento County Mental Health Treatment Center.

Patients could suffer relapses during their trips and potentially harm themselves or other people, said Kittrell and others. They could become lost to the streets, or commit crimes that land them in jail.

"The risk is just too great," said Dr. Marye Thomas, chief of behavioral health for Alameda County.

Southern Nevada Adult Mental Health Services has had an ongoing contract with Greyhound since July 2009, said bus company spokesman Timothy Stokes.

Stokes said he was unaware of any serious incidents involving mentally ill patients from Nevada. He said Greyhound has contracts with "a number" of hospitals around the country, but declined to identify them.

"We take it on good faith that the organization is going to make certain that patients are not a risk to themselves or others," he said.

Still, officials in several of California's largest counties said they rarely, if ever, bus patients out of state.

"We don't do it, we never will do it, and we haven't done it in recent memory, meaning at least 20 years," said David Wert, public information officer for San Bernardino County. Rawson-Neal has bused more than 40 patients to that county since July 2008.

Los Angeles County officials said they have not bused a single patient out of state during the past year, and when they have done so in the past they have supplied chaperones. In the past five years, L.A. County has received 213 people from the Nevada hospital, according to the Bee's review, more than any place in the country.

Likewise, in Riverside County, sending patients out of state "happens very infrequently upon request of the family," said Jerry Wengerd, head of the county's department of mental health. "A staff member accompanies the client and it is usually by air."

Nevada bused 20 patients to Riverside in the period reviewed. Sacramento County bought bus tickets for five patients during the past year, Kittrell said. In all cases, he said, facility staff confirmed before patients departed that a family member or friend would meet them at their destinations, and provided referrals for treatment.

DJ Jaffe, executive director of Mental Illness Policy Org, a nonprofit think tank, said his group often hears anecdotally about patients being "dumped" from one county to another.

"Discharging severely mentally ill patients inappropriately is policy in this country," Jaffe said. "But getting rid of them altogether by busing them out of state is, I think, rare. I am shocked by these figures. It seems to be almost routine in Nevada."

After California, Arizona has received the most patients by bus from Nevada, at more than 100 over the five years.

But Cory Nelson, acting deputy director for the Arizona Department of Health, cautioned against drawing conclusions about Nevada's practices based solely on number of bus tickets issued. In many cases, Nelson said, relatives could have agreed to house patients or made treatment arrangements before the clients left Las Vegas.

In rare cases, Nelson said, a hospital can find itself in a "catch-22" situation when a patient no longer needs to be in a hospital but refuses to cooperate with a discharge plan. "It kind of leaves a hospital in a tough situation," he said.

Still, the sheer number of patients bused from the Nevada hospital "does seem pretty high," he said.

Several people interviewed said the numbers might be explained in part by the unusual nature of Las Vegas.

"As the whole country no doubt knows, Vegas is a pretty unique place," said Dr. Lorin Scher, an emergency room psychiatrist with UC Davis Health System.

The city's entertainment and casino culture draws people from all over the world, Scher noted, including the mentally ill.

"Many bipolar patients impulsively fly across the country to Vegas during their manic phases and go on gambling binges," he said. "Vegas probably attracts more wandering schizophrenic people" who are attracted to the warm weather, lights and action, he added.

"I am by no means defending their practices," he said. "It certainly gives cause for concern. But it's one possible explanation."

Stuart Ghertner, former director of Southern Nevada Adult Mental Health Services, cited other possible reasons. He said Rawson-Neal has been under siege for years because of state budget cuts, a steady increase in poor people needing mental health services in the Las Vegas area and a revolving door of administrators.

He noted the city had a disproportionate number of people displaced by the housing and mortgage meltdown of a few years ago. "The casino boom was over, people were losing their jobs and their homes. They were stressed and they wound up in a mental health crisis," Ghertner said.

Between 2009 and 2012, Nevada slashed spending on mental health services by 28 percent to address budget deficits, according to data collected by the National Alliance on Mental Illness. Even before those cuts, Nevada fell well below the national average in spending on mental health services: In 2009, it spent $64 per capita on such services compared with a national average of about $123, according to the study.

"You're looking at a tsunami situation," said Ghertner, a psychologist who resigned last year after five years as agency director. "There is more pressure to turn patients over faster, and fewer programs (in which) to place them. Perhaps busing them became the easier solution."

It also is cheaper, he noted. Southern Nevada Adult Mental Health Services spent a total of $205,000 putting patients on Greyhound buses during the past five years, according to the Bee analysis. The state hospital admits about 4,000 patients a year to its inpatient unit, and inpatient care runs around $500 per day per client, Ghertner said.

He said he was aware during his tenure that Rawson-Neal was busing patients out of state but that he thought the practice was rare.

At the time, "I had 800 employees and a $106 million budget," he said. Ghertner regularly reviewed numbers pertaining to admissions, length of stay and other issues at the hospital, but patient busing was never on his radar, he said.

"I'm embarrassed to say that this practice was going on to this degree under my leadership," he said. "I had no idea. It just never came up."

Ghertner said the state mental hospital has been under stress since it opened in 2006, turning over five hospital directors since that time. That instability has taken a toll, he said.

"This busing issue is a symptom that reflects that the care there is not quality care," he said. "Things clearly are being missed."

Willden, Nevada's Health and Human Services director, said during last month's legislative hearing that policies have been tightened and disciplinary actions taken to ensure that patients are discharged only after the hospital confirms care and treatment at their planned destinations. The hospital administrator, Chelsea Szklany, now must approve all bus discharges ordered by medical staff, he said.

Rawson-Neal could lose vital federal funding pending an ongoing probe by the federal Center for Medicare and Medicaid Services. California State Senate President Pro Tem Darrell Steinberg has written a letter expressing outrage to U.S. Secretary of Health and Human Services Kathleen Sebelius.

The hospital's discharge practices also have prompted a call for action by a member of the U.S. Commission on Civil Rights. Commissioner David Kladney called for a broad investigation by Nevada's governor and Legislature.

"As a Nevadan, I am ashamed that my state is failing in its duty toward the neediest residents," Kladney said. Nevada, he said, appears to be "simply hoping that other states will shoulder the responsibility."